Provider Demographics
NPI:1538337498
Name:OTILLAR, LAURA JANE (PA)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JANE
Last Name:OTILLAR
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1200 ENCLAVE PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-1764
Mailing Address - Country:US
Mailing Address - Phone:281-870-1000
Mailing Address - Fax:866-513-0183
Practice Address - Street 1:1200 ENCLAVE PKWY
Practice Address - Street 2:STE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-1764
Practice Address - Country:US
Practice Address - Phone:281-870-1000
Practice Address - Fax:866-513-0183
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA02926363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant